The response was huge: So many distressed doctors (and medical students) wrote and phoned me. Soon I was running a de facto international suicide hotline from my home. To date, I've spoken to thousands of suicidal doctors; published a book of their suicide letters; attended more funerals; interviewed hundreds of surviving physicians, families and friends. I've spent nearly every waking moment over the past five years on a personal quest for the truth of "why." Guilt, bullying, exhaustion are big factors. Here are some of the things I've discovered while compiling my list and talking to so many people:

High doctor suicide rates have been reported since 1858. Yet more than 150 years later, the root causes of these suicides remain unaddressed.

Physician suicide is a public health crisis. One million Americans lose their doctors to suicide each year.

Many doctors have lost a colleague to suicide. Some have lost up to eight during their career — with no opportunity to grieve.

We lose way more men than women. For every female physician on my suicide registry, there are seven men. Suicide methods vary by region and gender. Women prefer to overdose and men choose firearms. Gunshot wounds prevail out West. Jumping is popular in New York City. In India, doctors have been found hanging from ceiling fans.

Male anesthesiologists are at highest risk. My registry also shows that most of these doctors kill themselves by overdose. Many have been found dead in hospital call rooms where they are supposed to be resting between cases.

Lots of doctors kill themselves in hospitals. They jump from hospital windows or rooftops. They shoot or stab themselves in hospital parking lots. They're found hanging in hospital chapels. Physicians often choose to die in a place where they've been emotionally invested and wounded.

"Happy" doctors also die by suicide. Many doctors who die by suicide appear as the happiest, most well-adjusted people on the outside. Just back from Disneyland, just bought tickets for a family cruise, just gave a thumbs-up to the team after a successful surgery — to mention only a few cases from my list — and hours later they shoot themselves in the head. Doctors are masters of disguise. Even fun-loving docs who crack jokes and make patients smile all day may be suffering in silence.

Family members of doctors who have killed themselves are also at high risk of suicide. Sometimes even by the same method. A year after a depressed Kaitlyn Elkins, a star third-year medical student, chose suicide by helium inhalation, her mother, Rhonda, died by the same method. At the mother's funeral, her husband told me, "Medical school has killed half my family."

Suicidal doctors are rarely homicidal. On the list of suicides I've compiled, only 2 percent (15) also involved homicide. Seven of those homicides were by male physicians who killed a female spouse/girlfriend (all in health care — four nurses, a nursing student, a pharmacy tech and a dentist) before killing themselves.

Three male physicians murdered their young children before taking their own lives. Another strangled his disabled adult daughter before killing himself. Less than 1 percent of all doctor suicides involve homicide of their children.

Of the three cases involving young children, all the suicide victims were having relationship problems with the mother. One also killed the mother.

Patient deaths hurt doctors. A lot. Even when there's no medical error, doctors may never forgive themselves for losing a patient. Suicide is the ultimate ­self-punishment. In several cases, the death of a patient seemed to be the key factor in pushing them over the edge.

Malpractice suits can be devastating. Humans make mistakes. Yet when doctors make mistakes, they're publicly shamed in court, on TV and in newspapers (that live online forever). Many continue to suffer the agony of harming someone else — unintentionally — for the rest of our lives.

Academic distress kills medical students' dreams. Failing medical-board exams and not getting a post-medical-school assignment in a specialty of choice has led to suicides. Doctors can be shattered if they fail to gain a residency: Before his suicide, Robert Chu, unmatched to residency, wrote a letter to medical officials and government leaders calling out a system that he said ruined his career.

Assembly-line medicine kills doctors. Brilliant, compassionate people can't care for complex patients in 15-minute slots. When punished or fired by administrators for "inefficiency" or "low productivity," doctors may become suicidal. Pressure from insurance companies and government mandates crush these talented people who just want to help patients. Many doctors cite inhumane working conditions in their suicide notes.

Bullying, hazing and sleep deprivation increase suicide risk. Medical training is rampant with deplorable conditions — such as working nonstop for 24 hours or more — that are not permitted in other industries. Physicians report hallucinations, life-threatening seizures, depression and suicide due to sleep deprivation. Fatigued doctors have felt responsible for harming patients. Resident physicians are now "capped" at 28-hour shifts and 80-hour workweeks. If they "violate" work hours (by caring for patients), they can be forced to lie on their time cards or be written up as "inefficient" and sent to a psychiatrist for stimulant medications. Some doctors kill themselves for fear of harming a patient as a result of their extreme sleep deprivation.

Blaming doctors increases suicides. Words such as "burnout" are often employed by medical institutions to shift blame to doctors for their emotional distress while deflecting attention from unsafe working conditions. When doctors are punished with loss of residency positions or hospital privileges for occupationally-induced mental health conditions, they can become even more hopeless and desperate.

Doctors who need help don't seek it because they fear mental health care won't remain confidential. So they drive out of town, pay cash and use fake names to hide from state medical boards, hospitals and insurance plans out of fear that they will lose state licensure, hospital privileges and health plan participation. (Even if confidential care were available, physicians in training have little time to access care when working 80 to 100 or more hours per week.)

Some doctors develop on-the-job post-traumatic stress disorder. This is especially true in emergency medicine, my registry suggests. One day, they just snap — like this ER doctor who contacted me after he tried to kill himself:

"My wife once asked how we do it in the ER, to be there for everybody's worst day and also for their best. My worst day was almost my last. Funny thing is, I was as happy as I had ever been in my personal life. My decision to end it all was 100 percent work-related."

The doctor had treated a girl in the ER for flu and then released her. She ended up back in the ER 30 hours later in respiratory distress and eventually died. His job was in jeopardy. "When I got home in the early-morning hours, I was just sad. I cried for the girl and her family. I cried myself to sleep and woke up still sad. . . . There's a saying we have in the emergency room when we witness trauma and death among the innocent: A little piece of my soul died. . . . We're almost never offered counseling, and in the end you get the jaded emergency doctor who struggles to care. My psychologist says it wasn't just the last girl. It was trauma after trauma after trauma." He took a handful of pills but ended up surviving and is grateful for it. Still, he writes "Emergency medicine once defined me. I loved going to work every day. I think at one point I was a good doc who cared about his patients. Now I am just very anxious even thinking about going back to work."

No time for our own pain

Like everyone else, doctors have personal problems. We get divorced, have custody battles, infidelity, disabled children, deaths in our families. Yet working 60 to 80 or more hours per week immersed in our patients' pain means we often have no time to deal with our own. I'm always surprised by how often nonmedical people tell me they are shocked that doctors have the same mental-health issues and personal problems that everyone else has.

Some people in the medical profession believe the public doesn't need to know that doctor suicide is a real problem, as if a healer being in pain is shameful and would frighten patients. (A few years ago, I was honored to be invited to a special event hosted by the American Medical Association. They were interested in previewing a TEDMed talk I was scheduled to give about doctor suicides. But shortly before the event, I was disinvited: People were "uncomfortable'' with the topic, I was told.)

After collecting so many stories over the past five years I believe that ignoring doctor suicides just leads to more doctor suicides. Suicide is preventable, but we have to stop with the secrecy and face up to what it is about being a doctor that can be so emotionally difficult. I am hopeful that the forthcoming documentary "Do No Harm," by Emmy-winning filmmaker Robyn Symon will raise awareness on both points. In the meantime, medical institutions need to openly acknowledge the problem and make changes to support the mental health of doctors and medical students.

Healers, after all, also need healing.

Wible is a family physician born into a family of physicians. When not treating patients, she devotes herself to preventing suicides by medical students and physicians. Contact her at idealmedicalcare.org/blog/contact.

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